Amniotic Fluid Chemical Composition
Physiology
Function
Amniotic fluid is present in the amnion, a membranous
sac that surrounds the fetus. The amnion is metabolically
active and is involved in the exchanges of water and
chemicals between the fluid, the fetus, and the maternal
circulation; and produces peptides, growth factors, and
cytokines.
Volume
The amount of amniotic fluid increases in quantity
throughout pregnancy, reaching a peak of approximately
800 to 1200 mL during the third trimester, and then
gradually decreases prior to delivery.
• Polyhydramnios- amniotic fluid volume greater
than 1200 mL
• Oligohydramnios- amniotic fluid volume less than
800 mL
During the first trimester, the approximately 35 mL of
amniotic fluid is derived primarily from the maternal
circulation.
During the latter third to half of pregnancy, the fetus
secretes a volume of lung liquid necessary to expand the
lungs with growth.
After the first trimester, fetal urine is the major
contributor to the amniotic fluid volume. At the time that
fetal urine production occurs, fetal swallowing of the
amniotic fluid begins and regulates the increase in fluid
from the fetal urine.
Failure of the fetus to begin swallowing results in
excessive accumulation of amniotic fluid
(polyhydramnios) and is an indication of fetal distress,
often associated with neural tube disorders.
• Polyhydramnios may be secondarily associated
with fetal structural anomalies, cardiac
arrhythmias, congenital infections, or
chromosomal abnormalities
• Oligohydramnios may be associated with
congenital malformations, premature rupture of
amniotic membranes, and umbilical cord
compression, resulting in decelerated heart rate
and fetal death
The placenta is the ultimate source of amniotic fluid
water and solutes. Amniotic fluid has a composition
similar to that of the maternal plasma and contains a
small amount of sloughed fetal cells from the skin,
digestive system, and urinary tract.
The fluid also contains biochemical substances that are
produced by the fetus, such as:
 Bilirubin
 Lipids
 enzymes,
 electrolytes,
 urea,
 Creatinine
 uric acid, proteins, and
 hormones that can be tested to determine the
health or maturity of the fetus.
Measurement of amniotic fluid creatinine has been
used to determine fetal age.
Prior to 36 weeks’ gestation, the amniotic fluid creatinine
level ranges between 1.5 and 2.0 mg/dL. It then rises
above 2.0 mg/dL, thereby providing a means of
determining fetal age greater than 36 weeks.
Differentiating Maternal Urine From Amniotic Fluid
 Chemical analysis
• Creatinine
• Urea
• Glucose and
• protein
Creatinine does not exceed 3.5 mg/dL and urea does not
exceed 30 mg/dL in amniotic fluid, whereas values as high
as 10 mg/dL for creatinine and 300 mg/dL for urea may
be found in urine.
 Fern test
• A vaginal fluid specimen is spread on a glass
slide and allowed to completely air dry at
room temperature; then it is observed
microscopically.
• The presence of “fern-like” crystals due to the
protein and sodium chloride content is a
positive screen for amniotic fluid.
Specimen Collection
Indications for Amniocentesis
• Amniocentesis is recommended for neural tube
defects
• Ultrasonography (Fetal body measurements)
• Finding an abnormality on the ultrasound
• Fetal epithelial cells
 • All fluid for chemical testing should be separated
from cellular elements and debris as soon as
possible.

• Centrifugation or filtration

Color and Appearance

Specimen Collection
Collection

• Amniotic fluid is obtained by needle aspiration

into the amniotic sac, a procedure called
amniocentesis.

• transabdominal amniocentesis.

• Using continuous ultrasound for guidance

• A thin, hollow needle is inserted through the
mother’s abdomen into the mother’s uterus and
into the amniotic sac to aspirate the amniotic
fluid.
• Amniotic fluid is obtained by needle aspiration
into the amniotic sac, a procedure called
amniocentesis.
• transabdominal amniocentesis.
TESTS FOR FETAL DISTRESS
HEMOLYTIC DISEASE OF THE NEWBORN
• The oldest routinely performed laboratory test on
amniotic fluid evaluates the severity of the fetal
anemia produced by HDN
• Amniotic fluid bilirubin is measured by
spectrophotometric analysis using serial dilutions

• Using continuous ultrasound for guidance COLOR SIGNIFICANCE

• A thin, hollow needle is inserted through the

COLORLESS NORMAL
mother’s abdomen into the mother’s uterus and
into the amniotic sac to aspirate the amniotic
BLOOD-STREAKED TRAUMATIC TAP,
fluid.
ABDOMINAL TRAUMA,
INTRA AMNIOTIC
HEMORRHAGE

YELLOW HEMOLYTIC DISEASE OF

THE NEWBORN

DARK GREEN MECONIUM

• A condition wherein the Red Blood Cells of a

newborn or prenatal fetus is destroyed, resulting
in anemia.

• Occurs when there is a mismatch of blood antigen

between the mother and the baby.

PURPOSE OF THE PLACENTA

• Separates the mothers blood from fetal blood.

• 1st mismatch of antigen is not at risk, but the

succeeding mismatches is at risk.

Instances that affects the placenta’s duty

Specimen Handling and Processing
• Birth
• Fluid for fetal lung maturity (FLM) tests should be
placed in ice for delivery to the laboratory and • Miscarriage
kept refrigerated.
• Abortion
• Specimens for bilirubin testing must be
• Blood transfusion/sharing needles
immediately protected from light.
• Trauma
• Specimens for cytogenetic studies or microbial
studies (room temperature or body temperature) CLINICAL SIGNIFICANCE
• 37°C incubation • Anemia
 • Jaundice (air sacs of the lung) to remain open throughout
the normal cycle of inhalation and exhalation.
• Enlarged liver, spleen
• The surfactant concentrations are too low, the
• Erythroblasts in blood of newborn
alveoli will collapse, causing RDS.
PREVENTION
• The amount of surfactant in fetal lungs can be
(FOR HDN THAT INVOLVES D ANTIGEN ONLY)
estimated by measuring the amount of
• Administer Purified anti-D antibody to mothers surfactants in amniotic fluid.
during and after detection of antigen mismatch
Lecithin-Sphingomyelin Ratio
pregnancy.
• reference method to which tests of FLM
• The antibody binds to the fetal blood that leaks to
the mothers blood, and either destroys or hides • Lecithin- primary component of the surfactants
them from the blood components of the mother (phospholipids, neutral lipids and proteins) that
make up the alveolar lining and account for
TREATMENT
alveolar stability.
• INTRAVENOUS FLUID
•  produced at a relatively low and constant rate
• PHOTOTHERAPHY until the 35th week of gestation

• BLOOD TRANSFUSION • Sphingomyelin- lipid that is produced at a

constant rate after about 26 weeks’ gestation
Neural Tube Defects
• Lecithin and Sphingomyelin appear in the
• Neural tube defects (NTD) are one of the most amniotic fluid in amounts proportional to their
common birth defects in the United States. concentration to their concentrations in the fetus.
• The two most common type of NTD: Phosphatidyl Glycerol
• Spina bifida • phosphatidyl glycerol (PG), is also essential for
• Anencephaly adequate lung maturity and can be detected after
35 weeks’ gestation.
 Common cause:
• If the respiratory distress occurs in the presence
• Diabetes of an L/S ratio of 2.0, therefore, a thin-layer
• Obese chromatography lung profile must include
lecithin, sphingomyelin, and PG to provide an
• Smoking accurate measurement of FLM.
• Maternal serum alpha-fetoprotein (MSAFP) blood Test for Phosphatidyl Glycerol
test, high-resolution ultrasound, and
amniocentesis. • an immunologic agglutination test for PG has
provided a more rapid and easy to perform
• Alpha-feto-protein (AFP) is the major protein method for assessment of fetal maturity.
produced by the fetal liver during early gestation.
• Aminostat-FLM uses antisera specific for
Both serum and amniotic fluid AFP levels are reported in phosphatidyl glycerol and is not affected by
terms of multiples of the median (MoM). specimen contamination with blood and
meconium.
• Normal values are based on the week of
gestational age, as the fetus produces maximal • reported as either negative, indicating pulmonary
AFP between 12 and 15 weeks gestation immaturity, or low positive or high positive,
indicating pulmonary maturity.
• Elevated amniotic fluid AFP levels are followed by
measurement of amniotic acetyl cholinesterase
(AChE).

Tests for Fetal Maturity

• Respiratory distress syndrome (RDS) also known

as hyaline membrane disease is the most
frequent complication of early delivery and is the
seventh most common cause of morbidity and
mortality in the premature infant

• This disease is caused by an insufficiency of lung

surfactant production and structural immaturity Foam Stability Index
of the fetal lungs. • Mechanical screening test called ‘’FOAM’’ or
•  Lung surfactant- substance that normally ‘’SHAKE’’ Test.
appears in mature lungs and allows the alveoli
 • Obtained using the platelet channel automated
hematology analyzers using either optical or
impedence method for counting.

• ADVANTAGES

(1)Rapid turnaround time (2)Low reagent cost (3)Wide

availability

(4)Low degree of technical difficulty (5)Low volume of

amniotic fluid required and (6) Excellent clinical
performance.

• The test cannot be used with contaminated

amniotic fluid.

Microviscosity: Flourescence Polarization Assay

• This assay provides a fluorescence polarization (P)

surfactant:albumin ratio.

• The microviscosity of lipid aggregates in the

Lamellar Bodies
• Layered storage granules.
• Type II pneumocytes of the fetal lungs at about
24 weeks of gestation, absorbed into the alveolar
spaces.
• Increases the OD of the amniotic fluid.
amniotic fluid may be assayed by mixing the fluid
with a specific fluorescent dye that becomes
incorporated in the lipids of surfactant.
• The intensity of fluorescence is measured by
polarized light. Dye bound to surfactant has a
longer fluorescence lifetime and exhibits a low
polarization.

Lamellar Body Count • P value is high with low levels of surfactant, P

value is low with high levels of surfactant.
• The degree of fluorescence polarization is
inversely proportional to the quantity of
pulmonary surfactant present.

REFERENCE:

Strasinger, S.K, Di Lorenzo, M.S (2014). Urinalysis

and Body Fluids (6th ed.) Philadelphia: F.A Daviss
Company